Lasting Lung Damage Found in 9/11 First Responders

Action Points

Explain to interested patients that this study found that rescue workers at the World Trade Center site suffered lung damage that persisted through seven years of follow-up.

The terrorist attacks on the World Trade Center on Sept. 11, 2001, left thousands of rescue workers from the New York City Fire Department -- both firefighters and emergency medical services personnel -- with lung damage that persisted for at least seven years.

The damage occurred primarily within the first year after the attacks, with average declines in forced expiratory volume in one second (FEV1) of 439 mL for firefighters and 267 mL for EMS personnel (P<0.001 for both), according to David Prezant, MD, of Montefiore Medical Center and Albert Einstein College of Medicine in New York City, and colleagues.

There was no recovery seen through Sept. 11, 2008, they reported in the April 8 issue of the New England Journal of Medicine.

"For the most part, our FDNY firefighters and EMS workers were the most heavily exposed, and, therefore, if we can find out how they're doing we can help others with lesser exposures to think about how they will be doing," said Prezant in an interview.

Prezant, who is also chief medical officer of the FDNY, and his colleagues had access to pre-attack lung function values, which were obtained as part of routine occupational health assessments.

From March 12, 2000 through Sept. 11, 2008, spirometric measurements were obtained every 12 to 18 months from both active and retired FDNY rescue workers.

Of 13,954 workers -- 11,868 firefighters and 2,086 EMS workers -- who were present at Ground Zero for up to two weeks after the attacks, 91.6% agreed to participate in the study.

Median follow-up was 6.1 years for firefighters and 6.4 years for EMS workers.

The lung function of the workers in the first year after the attack was previously reported in 2006. The declines in FEV1 occurred at about 12 times the rate seen with normal aging (about 20 to 56 mL per year in healthy nonsmoking men).

The largest reductions struck firefighters who arrived on the morning of Sept. 11, when the dust cloud was the thickest. Those individuals had a mean reduction of 585 mL in the first year.

Among workers who had never smoked, the proportion who had lung function below the lower limit of normal jumped from 3% before the attacks to about 13% during follow-up for firefighters and from 11% to 22% for EMS personnel.

The lack of recovery was surprising, because of previous experience with firefighters, according to Prezant.

The vast majority of firefighters who are exposed to smoke develop relatively mild respiratory impairment initially, followed by eventual recovery to normal levels.

That might not have occurred after the terrorist attacks because of the nature of the exposure, Prezant said.

Fires typically are not accompanied by the immense amount of particulate matter from pulverized building materials found at Ground Zero. In addition, he said, although fires release many noxious chemicals, most do not involve burning jet fuel.

The lack of recovery in the current study "highlights the need for further monitoring, for aggressive treatment, for identifying those who are at the lower levels [of lung function] and to treat them even more aggressively," Prezant said.

In an e-mail, James Sublett, MD, an allergist at the University of Louisville in Kentucky, said emphasizing worker protection at the World Trade Center site would have likely reduced the amount of lung damage observed.

"The urgency of the search and rescue efforts led to first responders not being diligent in protecting themselves from the dust cloud by wearing properly fitted respiratory protection, such as disposable NIOSH (National Institute for Occupational Safety and Health) N95 masks," he said.

But the answer may not be as simple as telling workers to put their masks on, because the respiratory protection equipment is uncomfortable and limits communication on the ground, according to Prezant.

"It is very difficult in ... this type of incredibly dangerous, arduous work environment to wear respiratory protection every minute you're down there," he said.

Prezant and his colleagues acknowledged several limitations of the study, including the fact that spirometry was not performed in the first days after the attacks and the type of spirometers used for monitoring was changed in 2002.

They also noted that they were unable to analyze the effect of the use of masks or respirators on lung function because the devices were not extensively used in the first week of exposure.

Furthermore, they wrote, there is uncertainty about whether the workers who did not participate in the study had systematically different lung function values compared with participants.

This article was developed in collaboration with ABC News.

The study was supported by grants from the National Institute for Occupational Safety and Health and the NIH.

Prezant reported receiving grant money for the World Trade Center Program from NIOSH through a cooperative agreement with FDNY. He made the following additional disclosure: "Retirement disability process at the NYC Fire Department is a multistep process. Several authors (Drs. Prezant, Kelly, and Weiden) participated in the first phase of this evaluation. However, the final determination is done by an independent physician review panel and no author of this manuscript has or has even served on that panel."

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